health professionals, and accreditation-driven measurement of care, such as the Healthplan Employer Data and Information Set (HEDIS).

Creating and Sustaining Behavior Change Through Systems Approaches: Case Studies from the Field

As reviews of continuing medical education illustrate, conventional continuing education workshops using lectures alone have shown little effectiveness in improving practice or even increasing knowledge that is retained over the long term. However, when a systematic approach is used for the application of information, positive effects on health outcomes can be achieved. Three examples of the process and tools used in systems successes are described below.

Example 1. The University of Virginia Institute of Law, Psychiatry & Public Policy had been involved for some time in training community mental health professionals about forensic issues (Melton et al., 1985). However, information was acquired, retained, and applied only after a system was put into place that included a joint memorandum from the state authorities about payment for evaluations, drafting of model orders, and meetings with key court constituencies to allay concerns about the quality of community-based evaluations. After those steps were taken, in just a few days of didactic workshops, the community clinicians acquired a level of forensic expertise commensurate with professionals in the field, and their reports were evaluated by legal authorities as substantially superior to those produced by hospital-based forensic clinicians. Furthermore, the clinicians expanded their expertise on their own, and they began to be used as experts on issues that were not included in the original training.

Example 2. The domestic violence prevention project at Kaiser Permanente, Northern California, utilizes the precede/proceed planning model and involves an assortment of tools for change in their program to improve the identification and management of family violence.

  • Predisposing factors are addressed through a training program for the team of health care providers, including small group training with role modeling and role playing, reinforced by video presentation.

  • Enabling factors in the clinic practice environment include posters, brochures, member wallet cards, provider toolkits with checklists and assessment forms, referral information, and linkages to community advocacy groups. Safe telephone numbers for subsequent contact with victims are elicited at the time of identification.

  • Reinforcing factors include departmental meetings with feedback and process measurement data and pay incentives for performance.

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